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Patient must be stripped to waist. Examined in good light. Examined in both upright and in lying down position. Examiner should sit or stand directly facing the patient.

The examination includes 2 parts :-




Venous pressure measured >3 cm above the sternal angle is considered elevated .

atrial systole x descent – onset of atrial relaxation c wave .slow positive wave due to right atrial filling from venous return y descent .small positive notch in the 'x' descent due to bulging of the AV ring into the atria in isovolumetric ventricular contraction.after the x' descent .rapid emptying of the RA into RV due to TV opening . v wave .NORMAL JUGULAR VENOUS WAVES a wave .

hyperkinetic states .widespread Visibility>>>palpability Obliterable Multiple pulsations Changes with  -respiration  -position  -abd.rapid Deeper.localised  <<< Not obliterable Single No change Not visible 1 peak/heart beat 1 descent.slow **seen in AR.pressure Upper limit visible  2 peaks/heart beat  2 descents.VENOUS PULSATIONS ARTERIAL PULSATIONS Medial to SCM b/w SCM 2 heads & clavicle Superficial .

These pulsations are severe enough to cause visible movement of ears or head with each beat of heart(Alfred de Musset’s sign). atheroma. and kyphoscoliosis. Prominent pulsation on right side of neck.CAROTID PULSATIONS      Carotid shudder – A coarse vibration at the height of carotid pulse said to be diagnostic of combined AS+AR. contd… . is referred to as Rowntree’s sign. Dancing carotids(Corrigan’s Sign) – Massive pulsation of neck carotid arteries observed in AR. Pulsating carotids are usually indicative of wide arterial pulse pressure. Kinked carotid artery – Males suggestive of coarctation of aorta. Females have a small pulsatile oval swelling in persons with hypertension. in hypertension.


EPIGASTRIC PULSATIONS  Epigastric pulsation may be cardiac. Cardiac pulsations Synchronus with apex More of retraction High up in epigastrium MS Lt sided pleural effusion Character Relation to apical thrust Thrust or retraction Location Causes Aortic pulsations Soon after apex More of thrust Low down in epigastrium Nervousness Transmitted pulsations by abdominal lump Aneurysm of abdominal aorta Hepatic pulsations Soon after apex More of thrust Right of the midline Enlarged pulsating liver in TR or TS . or hepatic in origin. aortic.

DISTENDED SUBCUTANEOUS ARTERIES :  Dilated and tortuos superficial arteries under the skin of the chest and back are a characteristic feature of coarctation of the aorta. Suzman’s sign? .

shape and type of chest Shape of the precordium Apical thrust Other pulsations of the precordium Other pulsations of the chest wall Suprasternal or episternal pulsation .      Size.

as in emphysema and severe kyphoscoliosis. or the straight back syndrome. and scoliosis.  They have a direct bearing on presence of atypical or abnormal physical signs in the chest as in funnel chest. It is also responsible for diseased condition of the heart. rachitic chest. .

A good sign for recognizing bulge in male is lateral displacement and elevation of left nipple in comparison with right. Causes : 1) Skeletal deformities 2) Diseases of lung and pleura 3) Diseases of heart or precordium . before implicating heart as the cause.Bulging or retraction of the precordium may be due to diseases outside the heart.  PRECORDIAL BULGING :. they should be ruled out first.

BACKWARD BULGE :1) 2) Pectus excavatum Shield chest PRECORDIAL FLATTENING :1) 2) Old pericarditis or adherent pericardium Fibrosis or collapse of lung Scoliosis or kyphoscoliosis 3) .


which can be appreciated. the site of the loudest murmur.e.  The maximal precordial pulsations may be due to  Dilated pulmonary artery  Large RV  Ventricular aneurysm  Aortic aneurysm  Hence THE DEFINITION OF APEX BEAT is the lowermost and outermost point of definite cardiac impulse.  It actually means point of maximum impulse i. .APEX BEAT v/s PMI : The term PMI is often used as a synonym for an apex beat.

and elderly subjects. In thin. apex is in 4th intercostal space. C. seen in 6th intercostal space. Infancy or childhood. D. Apical thrust is normally invisible in few persons due to 1) Heart being situated behind a rib 2) Thick chest wall 3) Pendulous breast 4) Emphysematous chest . In obesity. it may be displaced slightly outward and upward by the raised diaphragm.NORMAL VARIATIONS :A. abdominal distension and during pregnancy. narrow chested. B.

A change from recumbent to the upright position or even taking a deep breath may alter the position of the thrust. B. Mere shifting in bed from left lateral to the right lateral position may shift the apex as much as 11/2 to 2 inches. Failure of apical thrust to shift in this manner(with change in posture or on inspiration) is a sign of adherent pericardium. .POSTURAL SHIFT :A. C.

APICAL THRUST MUST BE OBSERVED FOR :  Presence or absence  Location. whether localized or diffuse  Direction of movement during systole. whether outward or inward (thrust or retraction)  Lack of mobility or fixation  Other characteristics . whether normal or displaced  Extent.

meteorism. sideways – pleural effusion.Due to A) Extrinsic or Extra cardiac causes I) Extra thoracic – scoliosis. downwards – aortic aneurysm. aortic and mitral valve disease .Displacement of apical thrust :. B) Intrinsic or cardiac causes I) Congenital – dextrocardia II)Acquired – hypertension. mediastinal new growth III) Intra abdominal – ascites. pneumothorax ii. straight back syndrome II) Intra thoracic – Displaced i. massive abdominal tumour or advanced pregnancy.

Extent of apical thrust :A) B) C) D) E) F) G) seen in Thin chest wall Hyperdynamic heart conditions Severe valvular regurgitation Left to right shunts Complete AV block Hypertrophic obstructive cardiomyopathy Retraction of lung from fibrosis or collapse Diffuseness of thrust is   A double systolic outward thrust is characteristic of HOCM. It is also seen in mitral valve prolapse and LV dyskinesia as in acute MI. .

a diagnosis justified only when retraction involves both ribs and interspaces (BROADBENT’S SIGN) .force is visibly increased in A) B) C) D) Thin chest wall Retracted lung Hyperdynamic heart LV hypertrophy as in hypertension or AR Cardiac causes of invisible apex :A) B) C) D) Weak action of heart as in MI or acute myocarditis Pericardial effusion Dilation of heart Dextrocardia Skoda’s sign :.(Negative cardiac impulse) It is sucking in or retraction during systole of the apical region. It may be due to A) Hyperdynamic heart with apex situated behind a rib B) Hypertrophied right ventricle.Force of apex thrust :. with forward thrust in the midprecordial area and retraction of apex C) Adhesive pericarditis.

Best observed by tangential inspection of precordial area. Physiological diffuse pulsation (wavy or peristaltic cardiac impulse) : Seen in  Thin chest individuals  Hyperdynamic hearts  During fever or after exercise  Retracted lungs Physiological para-apical retraction : A systolic retraction of chest wall between the apical region and sternum. Contd… . due to the sucking in effect of RV systole It may be mistaken for abnormal apex. It is however situated medial to true apex and is a retraction rather than a outward movement. preferably with patient recumbent with lowering his eyes level to anterior wall of patient’s chest.

the phenomenon is reversed . A heave in the left parasternal region may be due to LV hypertrophy.Left parasternal pulsation :    A systolic heaving of the mid precordial area. A central lift may be due to systolic expansion of left atrium from mitral regurgitation. Rocking or see saw movements : seen in massive hypertrophy of right or left ventricle. In RV hypertrophy. maximal between 3rd and 6th ribs is characteristic of massive RV hypertrophy. an inward movement of the apex is associated with an outward movement of the midprecordium during systole In LV hypertrophy.


Diffuse systolic retraction : A diffuse retraction of    precordial area. involving ribs and interspaces is due to the Tricuspid regurgitation Adhesive pricarditis Aortic regurgitation Lateral retraction in lateral decubitus position due to   Large RV or severe TR (with initial outward movement) Constrictive pericarditis: systolic retraction (with initial outward movement). followed by diastolic thrust .

MS or aneurysmal dilatation of P.  Aneurysm of descending thoracic aorta .  Retraction of left lung from fibrosis or collapse.artery.High thoracic pulsations : Observed in 2nd right intercostal space or behind the upper part of the sternum indicative of  Aneurysm of the ascending or transverse part of aortic arch  Dilatation of the aorta  AR Pulsations involving the 2nd or 3rd left interspace due to :  Dilatation of pulmonary artery as in PDA or septal defects.

Pulsations of sternoclavicular joint: Due to     Right side suggests right sided aortic arch Either side occurs in aortic dissection or aneurysm Systolic outward pulsation of upper half of sternum is due to aneurysm of ascending aorta Pulsation to right of sternum is due to dilated and unfolded ascending thoracic aorta and rarely due to large right atrium Pulsations in atypical situations CAUSE Empyema necessitates Lymphosarcoma Descending thoracic aorta aneurysm Innominate artery aneurysm Coactation of aorta LOCATION Pulsatile swelling in lateral aspect of chest wall Highly vascular tumour in mid sternum Back Supraclavicular region or upper part of thorax Interscapular and intercostal regions .

 Thyroidea ima artery.  Raised or uncoiled aorta as in hypertension.It may be seen in  Hyperdynamic heart.  Anemia.  Dilatation of aorta as in atheroma or syphilitic aortitis. .  Anomalous right subclavian artery.  Aneurysm of aorta.  Elongation and flexion of the innominate artery.